Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Age and Stroke Severity Matter Most for Clinical Outcome in Acute Arteriosclerotic Tandem Lesions

Background: Tandem lesions (TLs) cause up to 15-30% of all acute ischemic strokes (AISs). Endovascular treatment (EVT) is regarded as the first-line treatment; however, uncertainties remain with respect to the treatment and predictive outcome parameters. Here, we aimed to identify the clinical and demographic factors associated with functional short- and long-term outcomes in AIS patients with arteriosclerotic TLs undergoing EVT. Methods: This was a retrospective, mono-centric cohort study of 116 consecutive AIS patients with arteriosclerotic TLs who were endovascularly treated at a stroke center, with analysis of the relevant demographic, procedural, and imaging data. Results: A total of 116 patients were included in this study, with a median age of 72 years (IQR 63-80), 31% of whom were female (n = 36). The median NIHSS on admission was 14 (IQR 7-19), with a median ASPECT score of 9 (IQR 8-10) and median NASCET score of 99% (IQR 88-100%). A total of 52% of the patients received intravenous thrombolysis. In 77% (n = 89) of the patients, an antegrade EVT approach was used, with a good recanalization (mTICI2b3) achieved in 83% of patients (n = 96). Symptomatic intracerebral hemorrhage occurred in 12.7% (n = 15) of patients. A favorable outcome (mRS0-2) and mortality at 3 months were obtained for 40% (n = 47) and 28% of patients (n = 32), respectively. Age and NIHSS on admission were strongly associated with outcome parameters. Diabetes mellitus and previous neurological disorders were independently associated with long-term mortality (median 11 months, IQR 0-42). Conclusions: Younger age, lower stroke severity, and good recanalization were found to be independently associated with a favorable outcome. In contrast, older age, higher stroke severity, previous neurological disorders, and diabetes were correlated with mortality. The endovascular treatment of acute arteriosclerotic tandem lesions is feasible and relatively safe.

Timing of acute carotid artery stenting for tandem lesions in patients with acute ischemic stroke: A Maastricht Stroke Quality Registry (MaSQ-Registry) study

BACKGROUND

To better understand the influence of treatment strategies on outcomes for patients with tandem lesions undergoing acute internal carotid artery (ICA) stenting during endovascular treatment (EVT), this study compared clinical, technical, and safety outcomes in patients with acute ischemic stroke due to a large vessel occlusion (LVO) who underwent ICA stenting before versus after intracranial thrombectomy.

METHODS

This single-center retrospective cohort study included patients who underwent EVT due to a LVO and periprocedural ICA stenting for significant ICA stenosis or occlusion between September 2020 and January 2023. Data were extracted from the Maastricht Stroke Quality Registry (MaSQ-Registry). Primary outcome was the modified Rankin Scale (mRS) at 3 months. Secondary outcomes included procedure times, number of total thrombectomy attempts, first-attempt excellent recanalization rates (extended Thrombolysis In Cerebral Infarction (eTICI) ≥ 2C after one thrombectomy attempt), and safety outcomes.

RESULTS

This study included 50 patients. Thirty-one patients (62%) underwent ICA stenting before intracranial thrombectomy. No significant differences between both groups were found regarding mRS, total procedure time, number of total thrombectomy attempts, first-attempt excellent recanalization, or complications. Time between groin puncture and recanalization (reperfusion time) was significantly longer in patients who had ICA stenting before intracranial thrombectomy versus after intracranial thrombectomy (45 min versus 28 min, P = 0.004).

CONCLUSION

ICA stenting after intracranial thrombectomy in patients with tandem lesions undergoing EVT did not lead to better patient outcomes compared to stenting before intracranial thrombectomy, despite shorter reperfusion times.

Diagnosis and management of tandem occlusion in acute ischemic stroke

Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.

Balloon-Assisted Catheterization of Occluded Carotid Artery (BOCA) Technique in Acute Stroke

BACKGROUND

Acute ischemic stroke from tandem occlusion of internal carotid artery (ICA) poses a technical challenge to neurointerventionalists.

OBJECTIVE

To present a novel balloon-assisted catheterization of occluded carotid artery (BOCA) technique used for rapid and effective catheterization of occluded/critically stenosed ICA in tandem occlusion.

METHODS

A retrospective review of 10 patients with tandem carotid occlusion, treated with BOCA technique for revascularization between July 2020 and June 2021, was performed. Clinical, radiographic, and procedural data; details of BOCA technique; complications; and outcomes were reviewed.

RESULTS

Of the 10 patients, 8 (80%) had complete occlusion of the cervical ICA and the remaining 2 had high-grade stenosis with poor intracranial flow. The mean age was 63.2 years. The mean presenting NIH Stroke Scale was 13.4. The BOCA technique resulted in recanalization of ICA in all patients and allowed mechanical thrombectomy of middle cerebral artery. Thrombolysis in cerebral infarction grade 2b/3 was achieved in all 10 patients. The mean groin-to-reperfusion time was 41.4 minutes. The mean internal carotid artery stenosis was 99.7% preoperatively and 41.1% postoperatively. Only one patient needed stent at the end of the procedure because of dissection.

CONCLUSION

The BOCA technique can be used in distal first approach for acute stroke from tandem ICA occlusion. This technique allows direct guide catheterization of occluded ICA by tracking over a partially inflated balloon.

Bailout technique for entangled stent retriever and carotid stent during tandem large vessel occlusion endovascular therapy

BACKGROUND AND IMPORTANCE

Endovascular thrombectomy for patients with tandem occlusions could be challenging. Exposure to potential technical complications and bailout rescue techniques are of utmost importance.

CLINICAL PRESENTATION

A 73-year-old woman with tandem internal carotid artery and middle cerebral artery lesions underwent an unsuccessful retrograde revascularization approach in the setting of tortuous anatomy. Antegrade approach revascularization was then pursued. Following cervical internal carotid artery revascularization, a triaxial system of aspiration catheter, microcatheter and micro guidewire was navigated through the stented curved cervical ICA and intracranial stent retriever pass was performed. Upon retrieving the clot-incorporated stent retriever with the intention to retrieve the entire stent retriever into the locally placed aspiration catheter, the triaxial system collapsed into the distal common carotid artery. Large thrombus was recovered from the aspiration catheter aspirate however the proximal end of stent retriever and distal internal carotid artery stent got tangled. After unsuccessful maneuvering to disentangle stent retriever from the internal carotid artery stent, we decided to attempt safe separation of the stent retriever from its pusher wire and leave behind the patent internal carotid artery stent/stent retriever metal construct in place. Gradual pulling pressure was applied to the stent retriever wire while maintaining distal exchange-length microwire access and fully inflated extracranial balloon over the entangled portion to ensure continuous vascular access. The stent retriever wire was then safely separated from the stent retriever and fully retracted outside the body. Delayed angiographic runs continued to demonstrate full patency of the internal carotid artery lumen. No residual dissection, spasm, or thrombus was noted.

CONCLUSION

This case illustrates a novel bailout endovascular salvage technique that could be considered in such cases. These techniques minimize intraoperative complication, focus on patient safety, and promote efficiency for endovascular thrombectomy in unfavorable anatomy.

Acute tandem occlusion stroke in internal carotid artery and fetal posterior cerebral artery: endovascular management

INTRODUCTION

When the posterior cerebral artery arises from the internal carotid artery with an absent P1 segment, it is called fetal posterior cerebral artery (FPCA). It is unclear whether FPCA increases the risk of acute ischemic stroke, and the endovascular treatment of acute ischemic stroke due to acute occlusion of FPCA is not well established.

CASE REPORT

We report a case of acute ischemic stroke due to tandem occlusion of internal carotid artery and ipsilateral fetal posterior cerebral artery treated successfully with acute stenting of proximal lesion and mechanical thrombectomy of distal lesion with excellent neurological and functional outcomes.

CONCLUSION

Although further investigations are needed to determine the best treatment of these patients, endovascular treatment of fetal posterior cerebral artery occlusion is feasible.

Effectiveness of Guiding Catheter Retrieval Balloon Technique in the Treatment of Acute Anterior Circulation Tandem Occlusion: A Retrospective Study

BACKGROUND

Tandem occlusion accounts for 10%-20% of all large vessel occlusion strokes and often yields a poor recanalization rate. The endovascular treatment of tandem lesions is still controversial. This study uses an endovascular treatment strategy, "guided catheter recovery balloon (GRB)" for the treatment of acute anterior circulation tandem occlusion.

METHODS

A retrospective design was adopted. The population included patients with acute tandem occlusion who received emergency GRB endovascular treatment. And the choice of stenting was made based on intraoperative radiography imaging. Recanalization was evaluated by the thrombolysis in cerebral infarction score after the operation. Three-month modified Rankin Scale follow-up results were recorded, and modified Rankin Scale ≤2 was considered favorable recovery.

RESULTS

A total of 55 patients aged 66.9 ± 8.5 years were enrolled, 37 of whom received stenting. The mean overall recanalization time was 46 minutes. Fifty (90.9%) patients achieved successful recanalization with a thrombolysis in cerebral infarction score of 2b-3. At the 3-month follow-up, the number of patients with favorable functional recovery was 28 (50.9%). The presence of hypertension was correlated with a favorable recovery outcome: 82.1% of the favorable recovery population had hypertension, and 55.6% of the unfavorable outcome population had hypertension (P = 0.033). There was no statistically significant association between stent application and favorable recovery outcomes (P = 0.504).

CONCLUSIONS

GRB technique showed a high recanalization rate when applied to the treatment of acute anterior circulation tandem occlusion.

Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis

BACKGROUND

The endovascular treatment procedure in tandem occlusions (TO) is complex compared to single occlusion (SO) and optimal management remains uncertain. The aim of this study was to identify clinical and procedural factors that may be associated to efficacy and safety in the management of TO and compare functional outcome in TO and SO stroke patients.

METHODS

This is a retrospective single center study of medium (MeVO) and large vessel occlusion (LVO) of the anterior circulation. Clinical, imaging, and interventional data were analyzed to identify predictive factors for symptomatic intracranial hemorrhage (sICH) and functional outcome after endovascular treatment (EVT) in TO. Functional outcome in TO and SO patients was compared.

RESULTS

Of 662 anterior circulation stroke patients with MeVO and LVO stroke, 90 (14%) had TO. Stenting was performed in 73 (81%) of TO patients. Stent thromboses occurred in 8 (11%) patients. Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 82 (91%). SICH occurred in seven (8%). The strongest predictors for sICH were diabetes mellitus and number of stent retriever passes. Good functional clinical outcome (mRS ≤ 2) at 90-day follow up was similar in TO and SO patients (58% vs 59% respectively). General anesthesia (GA) was associated with good functional outcome whereas hemorrhage in the infarcted tissue, lower mTICI score and history of smoking were associated with poor outcome.

CONCLUSIONS

The risk of sICH was increased in patients with diabetes mellitus and those with extra stent-retriever attempts. Functional clinical outcomes in patients with TO were comparable to patients with SO.